Healthcare Provider Details

I. General information

NPI: 1578912325
Provider Name (Legal Business Name): RENAT KUDYAKOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2016
Last Update Date: 01/07/2022
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 FOREST LN STE B446
DALLAS TX
75230-5647
US

IV. Provider business mailing address

7777 FOREST LN STE B446
DALLAS TX
75230-5647
US

V. Phone/Fax

Practice location:
  • Phone: 972-566-8822
  • Fax: 972-566-8861
Mailing address:
  • Phone: 972-566-8822
  • Fax: 972-566-8861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number340648
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP137445
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP137445
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: